Sacrocolpopexy remains the gold standard treatment of post-hysterectomy vaginal vault prolapse. Sacrocolpopexy is usually performed through an abdominal incision, although more recently, laparoscopic and robotic sacrocolpopexy has been utilized by pelvic reconstructive surgeons to reduce the morbidity associated with laparotomy. Sacrocolpopexy involves suspension of the vagina to the sacrum using an intervening graft material. Various materials have been used in this procedure, including both natural and synthetic materials, although permanent synthetic mesh is most often described, due to excellent long-term results described in the literature. Of the synthetic materials in use today, the most commonly used is type I, macroporous, monofilament, lightweight polypropylene. This material is well tolerated, easy to handle, and resistant to infection and erosion through tissues in the pelvis, especially the vagina. Most surgeons who perform sacrocolpopexy employ a “Y-shaped” configuration of the mesh. This configuration includes two extensions of the mesh that provide coverage to the posterior and anterior vaginal walls. During the surgery, the bladder is advanced off the anterior vagina and the rectum is dissected free of the posterior vagina by entrance into the rectovaginal septum. The mesh arms and then placed over the anterior and posterior vagina and sutured in place with multiple interrupted sutures. Once the vaginal sutures have been placed, the surgeon attaches the mesh to the anterior longitudinal ligament of the sacrum, either at the promontory or lower, in the hollow of the sacrum. Finally, some surgeons choose to bury the mesh under the peritoneum, to prevent the potential development of internal intestinal hernia and subsequent obstruction.
Management of the mesh arms can be somewhat challenging during surgery, especially during laparoscopic or robotic sacrocolpopexy. It is important to allow the mesh to lie down flat against the endopelvic vaginal fascia, so that it does not bunch up, which is felt to be a risk factor for dyspareunia, infection, mesh exposure, erosion and pain. There is a need for a mesh configuration that will assist surgeons in the performance of sacrocolpopexy.
A similar procedure can be performed with the uterus in place (sacrohysteropexy) or with the cervix in place after supracervical hysterectomy (sacrocervicopexy). With the latter procedure, access to the peritoneal cavity can be accomplished through the vagina and cervix, through a cannula placed transvaginally. Using that method, the mesh can be introduced through the cervical trocar and needles with suture can also be introduced and removed in this manner. There is also a need to develop a mesh configuration that can be used with sacrocervicopexy that can accommodate a transcervical access port.